Is health care a right or a business? It’s time to make a choice

The recent health care discussion in the media has centered around the implementation of the Affordable Care Act, now no longer a lengthy, inert document but rather a living, breathing manifestation of what should be a collective, unambiguous vision for the delivery of care in the United States. It is, however, anything but comprehensive in scope, and the coverage has primarily focused on crashing websites, politics, calls for resignations, and apologies.

The attention to these unfortunate blunders is merited. However, I believe they should be no surprise and were, in fact, inevitable. This is because we, once again, have shifted our attention to tactics without first agreeing on a strategic direction — the clear, comprehensive vision that must drive any sincere attempt at improving the delivery of care in this country. We still haven’t answered the most important question before us. Is health care a business or a right?

I once thought the most ethical solution lay somewhere in the middle, between individual responsibility and collective compassion, but I now feel strongly we need to choose a singular direction. If we look at the current system as a whole, it quickly becomes clear that it is rife with contradiction and lacks any clear, consistently applied assertion of our society’s values, treating different entities, all ostensibly operating in the same space, differently.

It appears we only struggle with calling medicine a business in the doctor’s office, at the “point of sale,” so to speak, in the places where care is actually delivered by those that actually deliver it. The other players in health care, including insurance companies and biopharmaceutical companies, have no qualms about clearly stating their position — they are engaged in business for the sake of profit.

If medicine is a business, though, then let’s all just call it that, move forward boldly, unapologetically, and look patients in the eye and say, “If you can’t pay for this, you’re on your own. It’s your life; it’s your responsibility.” And no more employer-subsidized managed care at work either, only privately purchased catastrophic insurance coverage with patients reaching into their pockets for any other care they need.

There shouldn’t be any shame in that approach. In this country, we don’t demonize good landlords simply because they demand their tenants pay rent. And employers generally don’t subsidize your rent or mortgage. Similarly, we don’t castigate or imprison restaurant or grocery store owners that turn away the hungry and homeless, nor do we mandate the purchasing of “food insurance.”

Yet food and shelter are both basic human needs, even more critical to survival than health care. Why should health care be any different, then? Sure, health care costs are exorbitantly high, but, once the existing schism between payor and patient is eliminated, costs will decrease necessarily. In fact, the exorbitant costs are, in part, the direct result of our historical attempts at treating health care differently.

If we started relying on insurance to pay our grocery bills, a gallon of milk would soon cost two hundred dollars. All goods and services, no matter how critical to survival, must be paid for by the individuals consuming them. Economics teaches us that any other approach leads to derangements of price and renders the protection of supply and demand impotent. This is particularly true of the inelastic goods and services found throughout health care; introducing third parties to execute payment guarantees perpetual price increases and leads to further misallocation of scarce resources. So if health care is truly a business, it must be run that way.

Or, conversely, let’s make health care an inviolable right of every citizen and hold our government solely responsible for its delivery. That’s also a viable solution that, in theory, has the power to bring equity and universality to the delivery of medical care and is not without documented precedent in our country. After all, it’s difficult to fully engage in “life, liberty, and the pursuit of happiness” when you’re either dead or suffering in silence, unable to afford life-sustaining care or medications.

But if we follow that path, we need to approach it without reservation as well. The entire industry would need to understand that profit, other than to sustain ongoing operations and modest lifestyles, is no longer a justifiable motive unto itself. In many regions of the country, the control over physician reimbursement by what borders on insurance industry collusion is so pervasive, so complete, that there already exists little real variability in remuneration, anyway. In many ways, health care has already ceased being a true “market” in those areas.

We don’t live in an imaginary world, one with unlimited resources available to satisfy competing wants, where the laws of economics can be bent to satisfy inviolable rights. The two concepts are, and always have been, distinct and irreconcilable. That is why we don’t have any “freedom of speech marketplaces” or “freedom of religion exchanges” where one can trade these rights for profit or procure insurance to ensure access to them.

More importantly, a hybrid system obliterates the benefits of either solution. Currently, patients are not only vulnerable to the dangers of unchecked corporate excess but also the bureaucracy and ineptitude of government. We are forced to endure the flaws of both without reaping the full benefits of either. Yet we choose to simply muddle somewhere in the middle, apply “patches,” and undertake “fixes.” And we insist on treating health care delivery differently than equally critical products and services in other industries.

We just haven’t made a choice. And until we do so, until we set aside political correctness and the false beliefs that have driven policy for far too long, the news will continue to be dominated by crashing websites and political posturing. There is nothing wrong with calling health care a right, and there is absolutely nothing wrong with calling it a business, but, in the real world, it simply can’t be both. So which one should it be?

Is health care a right or a business? It’s time to make a choice 189 comments

Comments are moderated before they are published. Please read the comment policy.

NewMexicoRam

I agree.
Enough of this “healthcare is a right, ” and then not cover doctors, especially primary care, for their expenses.
It’s just ridiculous, actually it’s beyond ridiculous.

Luis Collar, M.D.

Thank you for your comments. Health care is, in fact, not a constitutional right. Since you mentioned expenses, a good example of the stark differences between health care and virtually every other profession can be found by observing the legal profession. Because of the nonsensical manner in which health care policy has progressed, many people feel a long visit with a primary care physician is worth only about twenty to thirty dollars (we’ve conditioned this response due to the ubiquity of copayments in our system). The same people, however, seem quite comfortable with the fact that a similar meeting with any good attorney costs many times this amount. And lawyers, except in some cases where they will receive a percentage of any settlement obtained for their client, are always reimbursed for their expenses, fully, in addition to their fees. The cost of every phone call, every copy, every meeting, must be covered.Extending this analogy further, the legal profession has successfully steered clear of arbitrary adjustments to their accepted methods of compensation. For example, the legal profession does not have any mandatory “outcomes-based” compensation (again, except for settlements, where they choose to be paid that way because they feel they will win the case). If you hire a defense lawyer, or a divorce lawyer, or a lawyer to help you with the closing on your new house, you will pay that lawyer up front and irrespective of “outcome.” If you go to jail after being found guilty of your crime, the lawyer still gets paid. If it turns out the home you purchased had a lien on it you didn’t know about, you may be able to sue the lawyer for malpractice (though likely not successfully), but unless you prove it the lawyer still gets paid.

Suzi Q 38

Yes, but the legal profession has NOT accepted insurance payments similar to the manner in which physicians have. The insurance companies know not to “mess” with lawyers.

If you accept insurance, you accept the insurance company’s terms. For my PCP, I noticed that they paid him about $48.00 for my last visit. Atrocious! I pay my hairstylist about $35.00 to cut and style my hair.

I have hired lawyers before, and they want the money UP FRONT. They call it a “retainer.” The retainer gets spent fast, because they charge you for every little thing.

If physicians did that, patients would go elsewhere, so I do not know what the answer is.

I can only say that this dialogue has helped me with my business relationship with my PCP. I am not as impatient with his ways. I understand him a little more.

I am going to bring him and his office staff a surprise lunch this month, because he has been a good doctor and my PPO insurance has been cheap.

I think the answer will have to lie with the specialists, unfortunately. They will have to give up a little of their pay, so that you can get paid a little more.

The insurance companies are also going to have to rein in the hospital costs, and get those charges within normal ranges. Right now, the charges are “all over the place.”

I have been charged about $8K for an MRI of my C, thoracic, and lumbar spines, contrast and no contrast.
This is at a separate imaging facility.

The teaching hospital charged me $25K. Where should the insurance company tell me where to go get my imaging?

Also, if you need to go to a new teaching hospital to get a second opinion, they want to do it all over again. Why?? My surgeon claimed the images were not clear.
I hope that he was being honest.

Also we are charged facility fees. Garbage.
If a PCP charged the same for h/her office, we would complain.

DoubtfulGuest

To be fair, some specialists aren’t making it, either.

Silly question here, have you actually discussed money with your PCP or were you just saying you feel better informed now? It was my impression that money is a verboten topic, even though it affects, you know, everything.

Nice analogy on the haircut/styling, I wish more people would think about this. On top of that, how much even goes to the doctor’s salary after overhead, staff wages, etc. It’s mind-boggling.

Suzi Q 38

“…Silly question here, have you actually discussed money with your PCP or were you just saying you feel better informed now? It was my impression that money is a verboten topic, even though it affects, you know, everything….”

No, I haven’t discussed money with my PCP.
Money is not discussed, but I see the bills and amount he is paid.

I am more informed now.
I still feel that specialists, at $400K a year, make a lot of money.
I realize that they have studied longer, and are specialists, but they are still doctors.
They don’t need to make double + than that of the PCP’s salary.

DoubtfulGuest

I see – thanks. It’s too bad we can’t talk openly with them about money…might solve a lot of problems. I’ve heard of people paying cash for a longer visit. I read somewhere it’s illegal under a PPO plan, but I’ve heard of others doing it with seemingly no problem. I can’t find any good information about this and can’t recall my previous sources. Nothing very reliable, I’m sure.

I know of some individual specialists who make much less(<$100K), at least the last few years, they've really taken a hit. In terms of hourly wages this wouldn't be much at all. Agree with you on the overall $$$, I just think that both extreme ends of the salary range deserve a look as well.

PrimaryCareDoc

Yeah, that’s illegal to pay more than the doctor has contracted with the insurance company.

DoubtfulGuest

Thanks, I see. Is this also necessarily true in a situation where, say, one had insurance on file with the drs. office before (in a previous year)…is it illegal to have a longer self pay visit later w/o billing insurance at all? I’m sorry if these are incredibly stupid questions. I’m only asking about laws/rules, I know you can’t address my specific situation…I’ve seen inconsistent information and it’s very frustrating.

querywoman

Well, this is the perennial gripe of the family docs, internists, and pediatricians – that specialists get paid at too high a percentage!
I hate the term, “PCP.”
Most of us need more of the lower tech care and always will.

querywoman

Some lawyers want money up front. Personal injury lawyers, of which medical malpractice lawyers are a part, do not get paid in advance. They lose a lot of cases. Many are settled out of court, and they get a percentage of those settlements, just like in court winnings.
Most lawyers are not trial/court lawyers. They work for corporations and get paid salaries to read complex contracts and push paper.

Suzi Q 38

Thanks for the info.
The lawyers we had to hire were conservatorship lawyers. We needed to attain conservatorship of my FIL, who was married to the wrong person.

i never want to do anything remotely like that again, suffice to say the fight was so personal that I wanted to win even though it meant parting with a substantial amount of money.

querywoman

Suzi Q, the legal process to win a major case is agonizing. It feels great at the end, but that’s after a very long frustrating battle.
A lot of personal injury cases, and that includes stuff like worker’s comp, are routinely settled out of court.
The average lawyer is a professional paper pushed who works for a corporation. One I used to know who worked for a toy or some similar gizmo company said he looked at real estate contracts all day. He said they were so complicated it takes a lawyer to read them.
A lot of these civil lawyers work very long hours, as most doctors do.
Yeah, you told the story of your FIL’s wife not feeding him properly. What? An Ensure diet?
That would kill anyone’s appetite.
I asked someone with whom I made private contact to share my private info with you. She said, you did, but she thought you valued your privacy.
I told her that I understood, and that you may already have enough private contacts to handle. My own Facebook contacts grow every day, and I’m a stay at home introvert who can’t handle much.

Suzi Q 38

Thanks for your comments.
Yes, I prefer to remain private for now, as it is hard for me to keep up with the friends that I have. I enjoy talking with you, though.

querywoman

Yeah, it’s hard for me to keep up with what I have.

What you went through with your father in law had to be really rough.
Only a very small percentage of lawyers do conservatorship!
Like I said, most of them are corporate paper pushers. Then they have benefits and maybe profit sharing, etc.
They simple don’t compare with doctors.

querywoman

Lawyers only win less than half their cases. For medical practice, it’s significantly less. Then they do not get paid.
Lawyers are not being enriched by a third party payment system.
The only public way that lawyers get paid is through the court system, which is a very small part of the legal system.

Public defenders may have a steady income, but it’s not lavish.

Suzi Q 38

My friend is a District Attorney. I think he makes about $175K. He prosecutes murderers. I will look up his salary. He can’t be paid that much, because he and his wife live near us. I don’t consider our neighborhood wealthy, we are just very comfortable.

querywoman

And, if he’s county, he gets county benefits.

Suzi Q 38

True.

querywoman

“Due process” is an American legal standard, though I don’t think it’s in the constitution.
There is no effective “due process” system in this country for complaining against the medical system. Yes, you can complain against the IRS, and you will go through a process and steps.
Try complaining in the US about your doctor, even in a government hospital, and see how far you’ll get. The doctor at your bedside is always right.

Parkland Hospital in Dallas has been in federal legal trouble for not following Medicare complaint procedures and given a written response.

querywoman

Love the dislikes here! I see that my friend, Suzi Q, liked it!
Any industry that is heavily subsidized by the government, as most hospitals others, follow a similar complaint process.
However, the medical profession has generally been free not to follow appropriate complaint processes.
I promise all of you, this is changing!
You take government money, and you will soon be playing by government rules!

Suzi Q 38

“……You take government money, and you will soon be playing by government rules!”

Yes, I heard that the statute of limitations for complaints was about 7 years. Since the state medical boards don’t care because they are understaffed, maybe things will be different in the future.
Obamacare may “cut” harmed patients a break and look into a few more complaints.

It should be interesting.

hawkeyemd1

We’re a dying breed NMR. A dying breed, indeed.

Duncan Cross

Just like when we decided education was a right, and then all the private schools like Harvard and Yale and Princeton had to close. Or when we decided legal counsel was a right, and shuttered all those white-shoe law firms. Or when fair housing became a right, because now everybody has to live in communal apartments.

Luis Collar, M.D.

Again, respectfully, higher education (which is the category Harvard / Yale belong in) is not a constitutional right. For there to be any reasonably direct comparison between healthcare (at least in the context discussed here) and education, the following would need to happen:

1.) The constitution would have to be amended with a “right to higher education”.
2.) The government would have to legislate that, because it is a right, any private institution (e.g. Harvard or Yale) is forbidden from charging tuition in excess of 110% or 115% of what public institutions of higher learning charge.

If those things did happen, however, Harvard and Yale would soon no longer be viable entities financially. And the concept of legislating education that way would be as impractical and illogical as it is in healthcare.

Kristy Sokoloski

Very well said. I agree with this 100%.

Luis Collar, M.D.

Thank you for your feedback.

Duncan Cross

Actually, most of the rights in the Bill of Rights are not ‘natural’ rights, but made-up civil rights designed to help secure natural rights. Healthcare is a civil right, because it helps us secure our life, liberty, and happiness. Further explanation available here: http://www.kevinmd.com/blog/2012/10/health-care-civil.html

You don’t have a constitutional right to force anyone to provide you with free stuff, no matter how happy it would make you.

querywoman

Doctors do not have a constitutional right to get free stuff from drug companies.
I pay for everybody else’s health: through the cost of goods, utilities, and taxes.
So why did the US government let a seriously unequal health care system develop in this country?
Remember, most of the poor get health care free. If not eligible for Medicaid, they get very low cost or free care at public facilities.

Kristy Sokoloski

That supposed “free” healthcare for most of the poor are being paid by the taxpayers in each State whether it’s Medicaid or the low cost free care at public facilities. Yes, the patient that is in need of the care may not pay but in the end someone else does.

querywoman

So, what’s your point, Kristy?
I think the poor are a non-issue in the idea of expanding health insurance.
Someone pays for the poor. And they are already well-covered. The doctors who do their best care are usually on salary.
The middle class and the upper middle class are not well-covered. They pay a high percentage of their incomes for medical care.
A young doctor often trains on people who get tax-supported care. Then, he or she goes into a practice with working people who are constitutionally being gouged by the insurance companies or having to self pay. And we get mad when we think the doctors are charging us too much.

Kristy Sokoloski

I have friends that are using Medicaid and in some States they are not already well-covered. Some of them struggle to get the care they need or the medications they need to help manage chronic conditions.
As for saying that we get mad when we think the doctors are charging us too much, I used to think that until I saw first hand what goes on in the Primary Care offices (and other doctors offices for that matter) and I do not think that I am being gouged by my insurance. Although, if I were in a position to do self-pay I would gladly do it for all of my doctors but since I can’t I need to have insurance and I am glad that I have it.

querywoman

As a welfare worker of over 9 years, I developed a fair opinion of local medical doctors. The nearest VA hospital is awful.
I did not like my Medicaid clients to use private doctors. Most Medicaid private doctors are awful. They don’t get paid enough, so they find ways to jack up the costs.
The Medicaid population is best served at public clinics, hospitals, and universities where the doctors get paid on salary.
For the poor without Medicaid, getting in at a public or church clinic often involves long waits and several hours off work. They need an appointment-based system.

My years in welfare taught me certain things about doctors. It’s hard to pick up people on time when you work one on one, and one interview can stretch on forever.
You say you need your insurance to help pay. Is is it employment related?
The people who most need some kind of assistance to lower medical costs are the uninsured middle and upper middle classes.

FSmith

I would add that having a constitutional right to something does not mean the government should set a limit on how much it costs (if it is not free). The author’s point about grocers and restaurant owners is a good one. One can argue that food is necessary for life, liberty and the pursuit of happiness, so do food purveyors not have the right to charge for their products?

Luis Collar, M.D.

Thanks for the feedback and your comments as well.

Luis Collar, M.D.

I respectfully disagree that healthcare is a “civil right”. It is certainly important but is, in fact, not even as critical to survival as food or shelter (as I point out in the article). Yet even food and shelter are not federal, constitutional rights. As a society, we can decide to provide subsidies for food and shelter, but the phrase “constitutional right” has a specific legal meaning. Healthcare is clearly not a right in that sense.

Duncan Cross

Here and above, Dr. Collar, you are wrong about what rights are and where they come from. Many of our legal rights — education, fair housing, privacy — stem from interpretation of the 14th amendment. I think you would be more amenable to the idea of healthcare as a civil right if you understood your subject matter better.

Luis Collar, M.D.

Thanks again for the reply. I first replied to your comment regarding Harvard, Yale, etc… which is clearly considered higher education. No interpretation of any amendment could possibly yield an assumption of any currently existing right to higher education. There is no question about that. Higher education in this country is not a right. The state does not make any such guarantees, nor does the constitution support it. The government does protect your right to be free of discrimination in your pursuit of higher education, but in no way says that you have a universal, irrevocable right (for free, at reduced cost, as a birthright, so to speak) to it.

There is also no universal right to housing (I assume you are referring to the Fair Housing Act / Civil Rights Act), at least not in the same sense as speech, religion, etc… What you are referring to as “fair housing,” or other legislative actions derived from interpretation of the fourteenth amendment, are not universal rights. Fair Housing deals with, amongst other things, protection from discrimination when pursuing housing opportunities, and in no way is related to any guarantee that everyone is entitled to a home or apartment for a reduced price or for free. There is a difference between a constitutional right and legislation that prevents discrimination or seeks to provide equal opportunity (of which there are many examples).

One is not allowed to discriminate when renting out an apartment. That is true. That is very different than anyone having a right to an apartment or house because it is their civil right to have that.

Duncan Cross

Again, you are wrong on what rights are and where they come from. To say healthcare isn’t a right in the Constitutional sense is trivial; the Constitution doesn’t create rights, it recognizes them. Humans have many more rights than the Constitution admits. Legal rights are claims won against governments, not presents given by them. One can quite reasonably claim there is a right to universal housing (and many do) without waiting for the government’s agreement. Why should I ask the government what it thinks my rights are? If healthcare is not yet a ‘federal, constitutional’ right — then I intend to win it. Saying it’s not simply puts you on the government’s side of that fight.

Luis Collar, M.D.

While I understand your political / philosophical position, effective policy cannot be developed based on imagined / desired rights that are currently not recognized as such. For example, you again assert a right to universal housing that does not exist. Your position is that you could assert it and then fight for it. That point is well understood, but I am correct in saying that there is a fundamental / practical difference between Constitutional rights, or rights recognized through subsequent legislation, and the desired “rights” that you continue to discuss. To illustrate this, there is a home for sale on my block that is currently empty. If you move in without buying the home, and then try to assert your “right to universal housing” when the police inevitably arrive to remove you from the home, you will quickly learn the difference between documented / recognized rights and theoretical ones. I use that example only to stress that, for the sake of a discussion about policy, whether or not something is an actual, legally recognized right is not “trivial”. Now that I understand your position, I would only reinforce the fact that nothing I have said about rights is “wrong.” Legally, and as a matter of policy, all of my assertions about currently recognized rights have been correct. I do understand your position, though. I just disagree with it. Thanks again for your comments.

Duncan Cross

If you want to be the Bull Connor in this scenario, be my guest. You’re gonna need more dogs.

Luis Collar, M.D.

Offensive, inaccurate comments do not further the discussion. I understand and respect your position; I am simply asserting my right to disagree with it. My goal is to improve the health of this nation; not to support untenable positions that would lead to poorer health for the vast majority of its citizens.

Duncan Cross

My position is I am asserting the right to healthcare, and I am fighting for it. You want to stand between me and my right, you’re gonna need all the dogs you can get.

NewMexicoRam

You are wrong, and just can’t see it through the liberal pink eyeglasses

hawkeyemd1

Amen…and if we make those other ones rights too, what happens when there is no more money, even from the “rich,” to pay for it all. Revolution? We need to make all these things affordable, and the best way to do that is to keep the government / rules / poor policy out of the way.

In my opinion this is a false dichotomy, because medical care is, and it can be, and most likely it should be, both (I don’t know what “health” care means).
There is no such thing as natural rights. Rights are determined by culture and social order. Our current social order decided that “freedom” (whatever that means, and it has evolved and it is still evolving) is a right. And freedom is not free. It costs a fortune in government, weaponry, law enforcement, etc. And it costs lives of soldiers and lives of civil servants. We pay for “freedom” of all varieties (e.g. speech, religion, bearing arms, due process) mostly through taxation. And the same is true for all other so called rights.
There are many businesses making a very nice penny providing us with our rights.
Media companies profit from allowing us freedom of speech (unless yelling in your kitchen is all it is). The Internet is chock full of businesses providing venues to exercise freedom of speech (we are using one right now).
All sorts of manufacturers (e.g. guns, tanks, uniforms, shoes, paper, software, furniture, cement, etc.) profit from enabling our freedom and are paid with tax dollars.
Hundreds of thousands of attorneys make a very nice living supporting our system of “rights”, including private and public ones, not to mention the judiciary, paid by tax dollars. And the list goes on…..
There is absolutely no reason I can see that medical care cannot follow the same paradigm, paid for with tax dollars and delivered by businesses.

Luis Collar, M.D.

Thank you for your comments. One of the goals of the article
was to
simply point out that current policy places physicians in the unique
position of treating health care as more of a “right,” while allowing
other players (insurance / pharma, etc…) to operate more in the realm
of “business” within the same system. I agree that both approaches may
be necessary, but one system cannot be both simultaneously and still
remain
consistent and efficient. Two distinct systems are required.
Actually, your examples precisely illustrate many of the inconsistencies
with the current approach.

1.) Freedom of speech is a constitutional right. And, as you
point out, the media does profit from “facilitating” that right. The
government,
however, does not mandate how much the media can charge you for
advertising with them, nor does it even force them to allow any one
individual to exercise that freedom. (You may want to exercise your
freedom of speech by appearing on CBS news, but they have the choice to
allow or not allow that.) As for this or any website, you can exercise
your freedom of speech here only at the discretion of those that own the
website. The government does not force them to allow it. Right and
business are distinct as it applies to speech.

2.) The right to bear arms is also a constitutional right.
And
gun manufacturers do, in fact, help you exercise that right. The
government, however, does not tell them how much they may charge you for
a weapon, nor do they even force them to sell guns to anyone. Again,
right and business are
distinct here.

Both of these are constitutional rights, and you therefore
are
also not forced to purchase insurance in the event someone denies you
access to them. If you are denied a constitutional right, you need only
turn to the courts. And while they are rights, the government does not
force any of the
ancillary businesses operating in those areas to
help you exercise those rights, nor do they control the prices they may
charge you. Those entities are, first and foremost, businesses operating
for profit.

Interestingly, health care is treated differently. It is not
a
constitutional right, yet the government (as well as private insurance,
though that is a separate topic) tells physicians how much they may
charge for providing services. In some instances, you are even forced to
provide that
service without regard to payment (e.g. emergency care /
emtala). It does not, however, force pharmaceutical companies to
provide free drugs, or insurance companies to provide free coverage.
They may do so if they choose, but they are
not forced to.

The
inconsistency extends to other industries as well. Food, like health
care, is not a constitutional right but is indisputably critical to
survival. And, as a society, we have decided that we
do not want to
see fellow citizens starve, so we have developed private (charity) and
public (food stamps) programs to help prevent this. But we do not tell
grocery store or restaurant owners that they must give food to the
hungry, nor do we tell them they can only charge 110% or 115% of the
price at which the hungry could obtain food from these other sources (as
is the case with Medicare).

There must be two completely distinct systems in order to
maximize
efficiency and fairness. One must be completely market driven and must
be completely free of any government intervention. The other can be
public and, because
of the use of public funds, can be regulated as
the government (and its citizens) sees fit. Trying to create one system
that is both, or creating a public system that intervenes in any way
with a private one, leads to inconsistency, inefficiency, and, because
they are the only ones at the front lines, places physicians in an
untenable position. The government has no right
to tell a physician,
under any circumstances, what he or she may charge for a service, no
matter what public programs a patient is part of. A right is a right,
and a business is a business. The two are distinct concepts. Any policy
that
attempts to blend the two will lead to increased inefficiency and lack
of parity (e.g. creates “winners” and “losers” amongst the parties
operating within it).

Dr. Collar, thank you for the eloquent reply. However, as you can probably imagine, I have a few clarifications in mind.
First, something being a constitutional right, or a legislative “entitlement”, presumably under the “general welfare” umbrella, is largely immaterial, I think. Both of those, as everything else we do, depend on one’s ability to pay, although a certain minimal level of protection may be provided from tax revenue.
Having a “right”, or being “entitled” to something doesn’t mean that someone else is to be forced to satisfy this right or entitlement without proper compensation and consent, in most cases. Draft to service in times of war is different and various eminent domain arrangements are also different, and I guess EMTALA is one of those things that are different, because of this notion we have that public good trumps individual liberties in dire situations.

As to physicians, in circumstances other than emergency care in a hospital, I don’t see how anybody forces anyone to provide any services for any prices. Physicians are not “forced” to accept Medicare/Medicaid and/or private insurance and/or cash. This is a contractual relationship, where the buyer offers a price and the seller can take it or leave it. In some cases, for private insurers, there is room for negotiation, directly proportional to the size of the seller.
The sheer size of the buyer is obviously a coercive factor, but that’s not much different than what, say, Walmart does to its suppliers of goods and labor. So much for the “free market” there.

I do agree with you that it seems contrary to the spirit of the constitution to force individuals into purchasing insurance at a price set by the insurer, and to add insult to injury, force taxpayers to subsidize increased profits of private insurers. I know that there is some regulation in place, but not enough to stop insurers’ stocks from going through the roof.

I also agree that letting other suppliers off the price regulation hook, such as pharma and device manufacturers, is equally irritating.
So yes, this is an extremely unfair and unbalanced system, and hence a convoluted and expensive one, but I don’t think we need two systems, or a two-tiered system.

Instead, a unified system, where prices are fairly and openly negotiated, and where corporations are not allowed to profit (not to be confused with physicians not being allowed to get exceedingly well for services), should satisfy the need or right or entitlement or common decency. I am also certain that a small market of luxury items will also be flourishing for the elite, in parallel. Maybe this is more like we all get police protection paid with tax money, but a few of us also hire private bodyguards for one reason or another.

Luis Collar, M.D.

Thanks again for your comments. Honestly, it seems we are in agreement in several areas. I suppose the main disagreement is in the use of the phrase “largely immaterial” as it applies to whether something is a right or not.

I firmly believe when we move toward tactics (reimbursement policies, insurance mandates, etc…) without first deciding the comprehensive philosophy driving a given policy, it can lead to inconsistencies, inefficiency, “winners” and “losers,” and many other untoward outcomes. For example, the amount of money available for health care (generally a large percentage of GDP) is fixed. Introducing mandates that further force third parties (e.g. insurance companies, the federal government) into the doctor patient relationship only serves to reduce the amount of money available for actual medical care. This is because insurance companies must extract a profit, and the federal government brings huge administrative costs to the process. Collectively, more money would be available for care if patients paid for more of their own health care directly. And, if health care is a right, it makes no sense to allow some private enterprises (insurance, pharma, etc…) to thrive more than others.

Your points on Medicare are well taken as well. However, physicians are, in fact, limited in what they can charge Medicare patients even if they opt out of the program. The government sets a maximum amount that these patients can be charged if a physician opts out. This is just one example, of many, where health care is treated differently than other “businesses”. (Thus my points about the food industry, which provides products that are even more critical to survival than health care but does not face similar controls on price or administrative freedom.) There is no precedent for this type of government intervention in any other industry.

I just think we would benefit greatly from a much more consistent approach (right or business) to health care policy and feel two distinct systems would be much more effective and efficient. There is no reason that physicians should face so many restrictions on what they can do for patients, or on how much they can bill, when there is no such limitation placed on other enterprises in the same industry, or on enterprises in other industries that are providing products or services just as critical to an individual’s well-being. This is not just about physicians making more money. It is primarily about the best way to have patients realize as much of their health potential as possible. Physicians are not the enemy. In fact, probably more than any other private parties involved in this system, they have patients’ best interests in mind. There is no reason, however, for physicians to feel “bad” about exercising their right to set a price, without the intervention of any third parties including the government, for their services.

I can definitely appreciate the reasoning behind your comments and thank you for taking the time to communicate those ideas. We agree on a lot, and I am by no means the global authority on these issues. So we can certainly agree to disagree on the remaining ones. Thanks again.

Whether one believes something is a natural or “God-given” right is a very personal choice, and, accordingly, I do not venture into that discussion here. I do, however, agree that healthcare is not a constitutional right (that is a fact, not an opinion), which is why attempting to treat it that way can only lead to inconsistency and inefficiency. My point is simply that “right” and “business” are conceptually and practically two different entities and must therefore be treated as such.

buzzkillerjsmith

This is a wealthy country, and it makes sense to give people here a right to basic health care. This of course leaves aside the question of whether the HC system is capable of doing that.

That said, you have to give incentives to docs, nurses, people who develop new drugs, and so on. People have to be paid enough to induce them to do the things we want they to do. The distinction between profit and other forms of payment is not that interesting for the purposes of this discussion.

But it still makes sense to regulate or even banish parasites in HC. The health insurance industry is mostly parasitical. I would submit that many health systems are parasites or at best profiteers.

The goal is to help people out most efficiently. If business has things to teach us about efficiency, lets learn them.

Right or business? I’m not sure I care about the words. More important is the process I described above.

Luis Collar, M.D.

Thanks for the reply. In my opinion, insurance (private or government-administered) is a big part of the problem. It limits patient choice and physician therapeutic autonomy, increases health care costs significantly, and reduces the total amount of money available at the bedside, without any direct correlation to improved patient health or collective outcomes. I’ve written about the implicit dangers of the ever increasing insurance footprint in heath care:

When I was taking my Sociology class and we covered the chapter about Healthcare I remember it mentioning in there about WHO’s definition of “health”.

querywoman

Just checked that definition. It’s vague. Nevertheless, I do not think it means submitting to regular blood pressure and cholesterol checks, submitting to regular cancer screening, and agreeing to treatment if guilty of any of the prior.
I have spent my adulthood in a medical system that trivializes my symptoms while asking me if I had this or that medical screening, then trying to coerce me into submission.

Suzi Q 38

My students tell me that there are so many people in China, that there is no health care if the patient has no money to pay for it.
Patients there without money just stay or go home to die.

We are lucky that this is not the case here, since we provide medicare and medicaid.
As far as healthcare being a “right?”
I am not so sure.

querywoman

I am researching health care in China now, just like I wrote earlier I can research US law anytime.
I do know abortion and birth control are readily available in China.

Suzi Q 38

Of course it would be.
The government is still are strictly enforcing their “one child” rule.
Sadly, some of those abortions are encouraged or enforced.
I know of many couples who were born in China, got married, had one child, then moved here. They have their second or third child once they get here.

They have such a population problem there that this is their solution.

querywoman

Perhaps China provides excellent care to maintain healthy organs in soon-to-be executed criminals.
It may not be easy to compare Chinese healthcare to US healthcare. It seems they still have some “barefoot doctors” who may provide a less technical level of primary care than routinely done here, which may be good.
When I research China and birth control preliminarily, I saw that, in Peru, when doctors focused too much on controlling fertility that their time got diverted from treating more serious illnesses and the sick went untreated.

You are probably right on this, too.
Yes, we can not compare the two.
Think about the many in our country who would not have any care at all since there is no Medicare or Medical.

Dana Freedman

“Think about the many in our country who would not have any care at all”

Before Medicare and Medicaid, people were still able to obtain medical care in this country. Remember, those programs only came in fairly recently. Even prior to to the 1960s, the average American still enjoyed better healthcare than the average Chinese person.

There was good healthcare in America prior to the explosion of government and private insurance, ask anyone who was around in the 50s.

querywoman

Ever increasing longevity in the US has also created certain procedures that aid illnesses associated with age and created a demand for them.
Examples, in the not too distant past, diabetes was a fatal illness. Now that we know how to treat it, we do.

hawkeyemd1

And, is some ways, the care was better and less complicated to get to as well.

querywoman

Suzi Q, Peru has conducted sterilization campaigns targeting indigenous women! Truly shocking, while their own doctors were needed to care for more serious illness.

disqus_qJEMXTKtR1

Is health care a right or a business?: Good question. Certainly haggling legally, ethically, financially, and morally over this issue is worthy. Bottom line though is the effect on the direction of our nation.

Almost all industrialized countries we compete with in the world have health care provided to their citizen. Without health care, our children and grandchildren will not be able to complete in the world market place.

It is already a business and overly dominates our per capita costs due to profits. We must now logically claim it as a right, or our country will continue to fail.

Gene Uzawa Dorio, M.D.

Santa Clarita, CA

Luis Collar, M.D.

Thanks for the comments. Many things affect the ability of a nation to compete, and many different things also affect the quality of life of a nation’s citizens. The question always revolves around the best way to allocate limited resources. For example, food / shelter / employment / higher education are all things that are critical to good quality of life, and they all have an impact on a nation’s ability to compete internationally. With limited resources available, however, which of these, and how much of each, should be subsidized by the state? And which private enterprises should be allowed to profit disproportionately for providing services in these subsidized areas? These are questions that are difficult to answer. If medical care moves to more of a free market approach, with patients more in control of how they spend their own health care dollars and physicians freed of insurance company / government administrative burdens and therapeutic control for at least some aspects of basic health care, costs would come down, and patients (the market) would decide where the limited resources would be best allocated. Whenever insurance industry / government intervention is removed from one aspect of care, prices for services in those areas will gradually decrease.

ninguem

Healthcare is not a right.

This is more than semantics. To carry that attitude around, that healthcare is a human right, does not help the goal of getting healthcare to everyone that needs it.

In fact, it makes things worse.

querywoman

Is a medical education a right? Is a large income a right?

querywoman

Ten dislikes! I’m not supposed to begrudge medical doctors an education or a large income, but it’s OK to begrudge me a costly medicine!
Selfish!

querywoman

Tam, I covered myself by saying “don’t think it’s in the constitution.” That meant I can research it and may find it there.
Quibble over something worthwhile, please!

DoubtfulGuest

Jumping in late here…It’s one thing to correct one another on facts, we should all be doing that, but I agree the tone of this discussion has been a bit too snarky.

querywoman

In capitalism, it seems the rights to make money and prosper are basic, protected rights.
Do certain people, like medical doctors, have the rights to live in 5 bedroom, 3 bath homes, and drive expensive cars by taking advantage of people unfortunate enough to need their help?
Okay, I have the rights to make money and prosper and not be constantly gouged by having to pay very high costs just to stay healthy!
I have some chronic conditions, which may be managed, and am perfectly capable of living a full life and contributing to society with some medical management.
I’ve been on the phone to Medicare tonight complaining about how my Medicare D plan gouges me for my Victoza later in the year when I’m not supposed to go in the donut hole. Tomorrow, I may write a US senator, know that I know more,.
I’ve been holding for 20 minutes trying to reach a different Medicare D insurer.

PrimaryCareDoc

Are you implying that doctors “gouge” their patients? You are aware, with very few exceptions, that doctors do not set their own rates, right? Costs of office visits and surgeries are set by insurance companies and medicare. As a matter of fact, doctors are forbidden from discussing or colluding with each other on costs.

I think that is quite the opposite of gouging.

As far as the cost of your Victoza- take it up with Big Pharma. Don’t blame doctors for that. Or, try taking insulin. Cheap, effective, and a hell of a lot safer than Victoza.

querywoman

PrimaryCareDoc, are you implying that physician income is not above criticism? Doctors who accept insurance as contracted payment accept insurance fees.
I never understood managed care. Supposedly, insurance negotiates with doctors and hospitals to get better rates. Is there any doctor who posts here who has ever negotiated with an insurance company? One therapist, when I I pointed this out, said, “There’s no bargaining. They just tell you you what it is.”
Managed care seems to be a form of collusion between the insurance companies and the biggies.
I am taking up the cost of my Victoza with big pharma. As for insulin, I have better disease control on Victoza, and am willing to take the risks.
I used to get 8 bottles of insulin a month, as I am very insulin resistant. If it’s $70 per vial now, that’s $540 per month. My Victoza is about $500 month.
And, my doctor will give me a sample every now and then.

PrimaryCareDoc

Right. So I don’t understand why you state, “Do certain people, like medical doctors, have the rights to live in 5 bedroom, 3 bath homes, and drive expensive cars by taking advantage of people unfortunate enough to need their help?Okay, I have the rights to make money and prosper and not be constantly gouged by having to pay very high costs just to stay healthy!”

You imply above that doctors are gouging and taking advantage of people so they can live large. Then you say here that doctors accept was insurance companies dictate and their is no bargaining.

I’m having a lot of difficulty trying to get what you’re saying.

querywoman

We’ll to reach a resolution. I want to have quality health care at a cost I can afford, just like a lot of doctors want to live in costly homes and drive costly cars, and send their children to private schools.
I may consider that some doctors live high, which is my right. Many of them probably spend every dime they have and live paycheck to paycheck, which is foolish.
Quibbling over whether or not health care in the US is a civil right is absurd. It’s here, and most of us want it.
My point on the insurance companies, the present payment system, is that most of you currently practicing doctors have NEVER bargained with an insurance company. It’s take it or leave it.
In the urban area where I live, it’s the ultimate in health care when, as many doctors do, refuse all insurance and are 100% self-pay.
Around here, they charge more!
As an aside, as a former welfare worker, I can help almost any person, even “upper middle class” who is uninsured find health care.
Most church hospitals will work out a payment plan for surgery with $1000 down.

hawkeyemd1

Definitely don’t think doctors are “entitled” to anything. And generally, when they get sick, they have to pay like anyone else does. They make some amount of money (many not as much as people think) because they went to school, worked hard, and ultimately make money. Anyone, in any career, has the same right. The right is not to healthcare, or a big house, or money in the bank. The right is about being allowed to pursue those things. With few exceptions, I think we do that (or used to do that) in this country. At the same time, we do need compassion and programs for those that can’t (for one reason or another) pursue those things the same way. But compassion is very different than designating it a right and having others pay for it.

querywoman

Yup. Glad you jumped in. And they make more than electricians and plumbers, who have been named capriciously on this thread.
I saw my dermatologist yesterday, who is a wealthy man, and he gets tons of drug money, which I mentioned to him.
He is a generous man. He is an activist on a mission, which not every doctor can be. He’d love to have more tools in his arsenal to treat complex skin diseases.
I have no problems with doctors who work get ting rich.
Some doctor’s wife blasted me here for not understanding how so many doctors are struggling. It’s inappropriate to whine about doctor income to a person who makes less.
Struggling patients face rising copays and monthly premiums every year when they are not getting a raise.

When I worked in welfare, my next door neighbor used to whine to our clients about his low pay. After he left, he realized he should not have done that in front of people who had less than him.
I see your last statement is about making others pay. We already pay plenty for the poor through Medicaid and other programs. The right to get cheap or low cost health care is already there for the poor. What about the rest of us

hawkeyemd1

I understand healthcare isn’t “easy” or “affordable” for too many people. We agree on that. The question is how do we decide what the Federal government should be involved in and what it shouldn’t be involved in? Healthcare is important, but so is education, housing, food, clothing, etc… The point is how do know where to stop. Has to be a better way than just waiting for the money to run out or the national debt to explode.

hawkeyemd1

Also, since you mention Medicaid. Medicaid itself has many problems (poor care, limited access, and others). So how can we be sure extending government intervention in healthcare to other people won’t make things worse. I’d like everyone to have access to care, question is what is the best way to do that. I struggle with believing the govt is best suited to get it done.

querywoman

Medicaid is substandard care, but it’s still care. Maybe they don’t get the most expensive meds, and don’t have access to many docs, but it’s still care.
Believe me, I’ve known plenty of people who want Medicaid. I was recently on the phone with a woman who says she is now financially secure and wanted some procedure that her private insurance wouldn’t cover, but Medicaid pays for it for its recipients.

People who don’t have Medicaid want it badly.
I have Medicare, which I don’t consider substandard. It’s been better for me than private insurance ever was.

Luis Collar, M.D.

Great points. Thanks for your contribution to the discussion.

PrimaryCareDoc

Also, why just put doctor’s salaries up for scrutiny? Does a hedge fund manager deserve to make several million a year? Do the higher ups at Goldman and Lehman Brothers deserve multi-million dollar bonuses every year? I guarantee you that they are making more than any doctor out there, and that industry receives PLENTY of money from the government.

querywoman

PrimaryCareDoc, what about the money the health insurance executives make? Are most of them doctors? If not, are they as educated as the medical doctors?
Most doctors don’t make the multi-million dollar bonuses that Goldman and Lehman Brothers do.
I know that.
To even compare the salary of a dollar to some of these CEOs is absurd.

Luis Collar, M.D.

I tend to believe many of the cost problems we currently experience in health care have come into existence precisely because doctors are not allowed to (in practice) set prices. If they had greater freedom to do so, if insurance and government intervention were removed from all but the costliest aspects of care, costs would decrease, physicians would be able to act with greater therapeutic autonomy / independence on behalf of their patients, patient and physician habits (ordering tests, prescription choices, goals of visits, etc…) would be much more in line with the limited resources available. Overall, any successful system needs to recognize two basic tenets:

1.) No one knows how to spend an individual’s money better than the individual himself / herself. Not the government, not insurance companies, nobody.

2.) No one is more qualified to determine the appropriate course of treatment / preventive care, etc… for a patient than a well-trained, independent physician. And no other single party in this industry (other than the patient himself / herself) has the patient’s best interests in mind more than physicians do.

A system that truly recognizes these two facts is needed. Anytime we violate either of these two basic principles with poor policy decisions, quality of care decreases, physician job satisfaction decreases, patient satisfaction decreases, costs increase, etc… Thank you for your comments.

Suzi Q 38

“In capitalism, it seems the rights to make money and prosper are basic, protected rights.
Do certain people, like medical doctors, have the rights to live in 5 bedroom, 3 bath homes, and drive expensive cars by taking advantage of people unfortunate enough to need their help?….”

Believe it or not, I think that they do.

This is why I understand why the PCP’s are complaining.
It is hard to pay for the office, fill out papers for referrals to specialists, deal with the insurance companies, Medicare, and Medi-cal, pay for the wages and insurances (including Workman’s Compensation) of their employees and then take a salary. Sometimes, the insurance companies don’t pay them for their services, and there is not much that they can do about it.

After going through all the schooling that they have gone through, they do deserve a good living. After all, while I was finished with school and working full time, I was paid well.
They were not. I was partying and hanging out with my friends most weekends, they were not. I got to get married, have our children, and spend a lot of time with them…they had to make those choices 5-10 years later.

I am fairly sure that I would not have survived organic chemistry in college….they did, and more.

I am not resentful of what they make at all.

I am resentful that some of the specialists are not realizing that they get far more than the PCP’s, so why not make the adjustment a little fairer. The specialists salaries are the ones that are not sustainable in the long term.

I also think it is ludicrous when I hear physicians who are specialists complain about the pay.

I think that $400K and up is a good salary, don’t you?

querywoman

This is a logical post, Suzi Q. It may be hard to get real information about physician salary and lifestyle. I do think $400,000 a year is excessive for a specialist, and would rather see generalists paid better.
Aren’t you in California? I am in Texas. The cost for standard of living is much higher in California.
Having to deal with the insurance companies is no fun. Most doctors are not good bureaucrats or paper pushers.
However, the very existence of third payment systems has entitled doctors to have a much higher standard of living than their predecessors 75 years ago.

fatherhash

you premise may be selfishly skewed….you are only looking at things as a consumer who feels entitled to things others have produced. victoza is expensive because the company that spent tons of money to make it is trying to make money on it(just as most inventors and companies would). keep in mind, that they likely also spent tons of money on inventing drugs that went nowhere. if you take away their freedom to produce drugs and charge what they want for it, why would they(or anyone else) continue to work hard to produce new meds.

if you don’t want victoza, don’t use it….use all the other generic diabetes drugs….but please don’t stop the drug companies from advancing/producing new meds.

querywoman

Fatherhash, your response is really strange. I have better disease control on Victoza, have lost 75 pounds, and am totally off insulin.
I doubt that aggressive diabetes management really saves any more. I think most of us would just die sooner without, and that probably would save the most money.

What I want is to consistently know in advance what my Victoza will cost. It’s $34 earlier in the year, and $75 later in the year.
I told my doctor at first that I might be willing to pay $70 month.
And why are drug companies willing to give so many of these drugs free to some people unless they are making a profit?

NewMexicoRam

Glad you’re doing better on Victoza, with obvious benefits, as you have discussed.
Probably would save more money in the long run to get rid of medical advancements, but is that the real point of medical care–to save money by having people die earlier? I know that’s not your point, but your 2nd paragraph could be used to make that argument.
Humor me for a minute. Doctors are facing a proposed 10 year freeze in Medicare payments, and I have a practice that is around 70% Medicare. For the last 13 years, Medicare has increased it’s payments to me by an average of 0.5 % per year. And it is likely that those same patients I serve will be getting 2% Social Security benefit increases each year for the next 10 years, having averaged a 2-3% increase in SSI payments for the last 13 years. Who is subsidizing who?

querywoman

Wow! Somebody who likes me!
I know Medicare has been slashing payments very slightly each year.
Yes, I think it should be raised slightly each year.
However, in the coming years, I think most of you will really appreciate your Medicare patients.
Medicare appears to be the system that will be most stable with the coming ACA.
Many private insurers are cancelling plans or jacking up the costs so much that the employed can’t afford them!
True chaos is coming!
Some people never go to docs, some only when sick, and some, like diabetics, have to go.
So what are you going to do if you have non-Medicare patients like chronic asthmatic and diabetic patients who get their policies cancelled?
In my younger years, I was just hypothyroid with occasional sinusitis attacks. Not that expensive! Now I cost plenty!

querywoman

Am I selfish for wanting what my doctor and I consider the best possible care for myself? I am no more selfish than people who want others to donate their organs.
I also use glimepiride and metformin.

fatherhash

selfish may be a harsh term, but essentially you want something(victoza)….but want others(medicare part D or discount by victoza manufacturer) to pay for it.

i’m not doubting that it’s a great medicine. nor am i saying you shouldn’t use it. just wondering how to get it to where you get it at a price you want…..the math just doesn’t add up.

querywoman

Fatherhash, why should you be surprised that insurance companies pay games with patients as well as doctors? They play even more games with the, “rich doctors,” like stalling on payments.
If you read all my posts, I told my doc initially that I was willing to pay about $70 month out of pocket for my Victoza.
Plus, for me, the Victoza probably costs at full price approximately what my many bottles of insulin did per month.

What angers me is insurance company games. I have had various responses as to why it costs $34 month, then jumps up to $75.44 month, starting in December last year.
Maybe I got the best response on the phone last night, but it is not clearly advertised in the literature.
I emailed a Medicare drug complaint addy last night. Someone from the insurance company called this morning, but I missed the call, and only have an 800 phone number for callback.
I also have a skin medicine, Cordran, for my face, that costs almost $700 for a bottle out of pocket. Most insurance doesn’t cover it, as skin meds are often not covered.
I called the drug program. I am not eligible to get the Cordran free, since I have Medicare D with state assistance. But, the phone answering person told me he could have the rep drop off extra samples at the doc’s office.
I already got plenty of Cordran from my derm.

The Cordran is to be used lightly, and is nowhere as costly as a year’s supply of Victoza.
My doctor will give me Victoza pens when he has them.

Dana Freedman

It’s probably no comfort to you, Querywoman, but I can empathize with your frustration in having to deal with multiple third parties (government, private insurers) whose policies and reasoning are about as clear as mud, when all you’re trying to do is keep yourself as healthy as possible. But it sounds like your problem is mostly caused by these third parties, and is not due to unreasonable greed on the part of your physician. Lashing out at doctors for “taking advantage of people unfortunate enough to need their help” doesn’t seem fair here.

querywoman

Dana Freedman, the doctors who write here like to blame insurance companies for all their problems. I point out that most of the doctors are living comfortable lifestyles.
It is a fact that medical doctors make a living off people who are unfortunate enough to need their help.
The standard of living for all of us is much higher than 50 or 75 years, and that includes for the poor.
So I point out that it’s not my fault if a medical doctor is having trouble maintaining his or her lifestyle which may include a 5 bedroom, 3 bath home, expensive cars, and private tuition for their children.
I’m living mostly okay on about $15,000 a year in a rented apartment, and complaining about having trouble maintaining my own lifestyle due to ever increasing drug and medical expenses.
So, it’s not astonishing that I question why a doctor needs a $500,000 home.

Such has been the situation most of my adult life!
Is it any harder to struggle through organic chemistry than to struggle through some health problems that I fought without adequate care for years?
I have plenty of education myself.

Luis Collar, M.D.

Great point.

querywoman

Here’s another jewel, Fatherhash. Last night, I began researching my Medicare D plan, Silverscript, associated with CVS.
I discovered that it has been sanctioned by Medicare and is not allowed to accept new enrollees! But CVS is still making a profit off it!
So why kneejerk me and make me out to be a whiny monster for complaining about unpredictable drug copays?

PrimaryCareDoc

Silverscripts sucks!!!!

querywoman

Ha! A doc made a nasty comment about SilverScript that landed in my email box, that apparently got deleted as offensive here.
I can’t believe I didn’t research SilverScript months ago.
I learned, since I get extra assistance, I can change my Medicare D at anytime.

querywoman

Tam, you had no idea how much of the constitution I have read. I can’t remember everything I have read.
I covered myself, by leaving a loophole that I wasn’t sure. I can read the U.S. Constitution, the Bill of Rights, and the Declaration of Independence any time I choose.

Free public education is only available through the 12th grade. I did not get my own bachelor’s degree through student grants and loans.
I can also interpret, “life, liberty, and the pursuit of happiness,” to include quality health care to maintain myself at a reasonable functioning level at a reasonable cost.

fatherhash

hypothetically speaking, what if a doctor didn’t provide the healthcare at a “reasonable” cost?….what would you have society do?….maybe enslave the doctor and force them to provide it?

querywoman

Fatherhash, the medical doctor has always been with us, even if he wasn’t able to do much for us since before the early 20th century.
Look at ancient Greek medical symbol that appears on so many medical buildings.
Britain and Canada still have medical doctors.

FYI, the current student loan system is a form of indentured servitude.

fatherhash

not sure if you really answered my question…you simply said that doctors have always been around. my question was on how to “force” doctors to provide something at a cost you find “reasonable.”

and yes, i agree, the current student loan system puts a burden on all professionals(doctors, lawyers, accountants, engineers, etc).

querywoman

I thought the question about did I want to enslave docs and force health care was extreme.
Doctors will continue to exist. They have to provide uncompensated care in the ER’s.
I think the ancient Greeks did have slave doctors.
And I think the biggest problem with contemporary US doctors starts in medical school, being exploited and coerced into massive debt.

Luis Collar, M.D.

This goes without saying, but if as a society we ever do decide to make health care an inviolable right for all citizens, the cost structure / financing of virtually every aspect of medical education would have to be completely overhauled. As an example, in the four years I was in medical school, tuition increased by almost 45% (about 9% each of my first two years, 15% for my third year, and then about 11% the year I graduated). My total tuition was almost three times the tuition paid by physicians that graduated from that same school only ten years earlier. Those types of increases are simply unsustainable in the long term, but I digress…

querywoman

Law students have started suing their universities and so far, losing.
I’m hoping that will change.
So when are you doctors going to start suing or uprising somehow about your medical schools?

disqus_qJEMXTKtR1

“Where things started to go downhill for us, was the beginning of socialized medicine with Medicare and Medicaid in fact.”

These programs served as safety nets for the aged and poor, and have done their job. Please provide supportive evidence initiating these programs was “where things started to go downhill for us.”

Fairly reliable evidence shows America is not #1 in health care, but hovers around #37 (WHO ranking). Despite great technology, we spend more percentage-wise of Gross Domestic Product (about 17%) providing medical care to our citizens than any country in the world. Why?

Worse, as you might know, many patients are relegated to medical care based on profit margin as opposed to our teachings during residency.

Medicare-for-all, socialized medicine, single-payer plans are all terms profit-seeking companies propagandize against, attempting to keep their system in place. We need to look at other world model such as in Taiwan, Netherlands, and the Scandinavian countries and see if they can be applied here.

Allowing over 40 million Americans not to have health insurance; the leading cause of bankruptcy to be medical bills with home foreclosures to be part and parcel to this; and insurance premiums to continually skyrocket does not serve the America people.

Like we do as physicians, it is our duty to recognize and define problems, then find solutions so our children and grandchildren remain competitive.

Gene Uzawa Dorio, M.D.

Santa Clarita, CA

hawkeyemd1

Agree with the need for a safety net as you say, but when does that net become too wide? Evidence of that happening (not just in medicine but throughout our society) is easily found by looking at our national debt, deficits, state bankruptcies… Granted, corruption and poor policy makes these situations worse, but how much more evidence do we need before we realize that the government can’t pay for everything?

querywoman

Is your car a civil right as per the Constitution? Lots of people assume I would have one and be glad to drive, but I don’t.
I stopped driving years ago and use public transportation.
Sometimes they seem to pity me or think it’s a sign of poverty.
It is not safe for me to drive!

Luis Collar, M.D.

Thanks for the reply. One of the goals of the article was to stress the need for consistency. Specifically, if it is more of a business (as it appears to be from the perspective of insurance companies or biopharmaceutical companies and others), then there is no reason that physicians should be treated differently. If we as a society at some point determined that it is a right, then that approach would need to treat all parties in a consistent fashion as well.

The comment on the legal profession was simply in reply to a comment that referenced the lack of compensation for PMD’s expenses. I don’t believe the medical profession can completely emulate the legal profession’s pay structure, but it can move more toward a traditional payment arrangement. The transition would be difficult, but allowing patients to pay for more of their own basic care, would, in fact, help drive health care costs down and free physicians from some administrative burden. To bring medicine more in line with a “free market” structure would, over the long term, drive efficiency, stimulate true competition and help control costs. A system where average patients pay for most basic care (programs would certainly still be in place for the very poor / children etc…) and secure catastrophic insurance coverage for the costliest therapies / procedures, would gradually drive down the costs for basic primary care, free physicians from the administrative burden and therapeutic control that insurance companies exert, and allow patients more freedom as to their therapy, choice in physician, etc…

querywoman

This thread starting out with questioning whether health care is a civil right or a business. So lots of people were arguing that it’s not a civil right.
I pointed out that I feel as entitled to receive my maintenance medical care at a decent, reasonable cost, and questioned if living a certain lavish lifestyle that many doctors have is their civil right.
And I got blasted!
My whining is as valuable as yours!

Judgeforyourself37

Primary care physicians do not make obscenely high salaries, and have to pay off, in many cases, horrendous student loans. Specialists, on the other hand often do make great salaries. There far too few PCPs, probably due to the inability to pay down those loans and thus they become hospitalists or specialists. Good for any doctor who becomes a knowledgeable PCP, being old, I have had several great doctors who were PCPs. I worked with pediatricians who were not highly paid, but some of them went through pre med and med school under the GI bill.

querywoman

I still hate the term, “PCP.” I agree that family docs, internists, and pediatricians should be better.
Surgery is the glory work, along with its very serious risks.
American glory work doctors seem to get more credit than the generalists.

PrimaryCareDoc

I don’t think anyone has claimed that doctors have a right to live a lavish lifestyle.

I also think your viewpoint is skewed. I know lots of doctors, and they live no where near the lavish lifestyles that I see from bankers, investors, etc.

FYI- I drive a 10 year old Honda with over 100,000 miles on it. Great car. I don’t live in a lavish five bedroom house. I don’t have a second property. My kids go to public school. I take one vacation a year- to Florida to visit my aging parents.

I have $163,000 left to pay off on my student loans.

Yup. Certainly livin’ the high life.

I love my job. But if I wanted to make a ton of money, I would have gotten an MBA.

querywoman

You are not living a high life. You are living a sensible life.
And if you read more of my posts, I maintain the real problem starts with the massive student loan debt, which really hits both doctors and lawyers very hard.
I do not consider most doctors, “rich,” because most of them work constantly to maintain their incomes.
Some docs live lavishly, and that’s different from being “rich.”

PrimaryCareDoc

Yes, that was me. 🙂

querywoman

I’m trying, dear doc. I should have googled them months ago. So I was stupid.

Suzi Q 38

“Stay the course,” Doctor, until those loans are paid off.

querywoman

See, Suzi Q, I’m not opposed to doctors prospering.
I can share frugally tips with the doc.
I buy brand new clothes with tags on them at my local thrift stores for as little as a dollar.

Luis Collar, M.D.

As a society, I believe we do need programs in place to help the most vulnerable members of our society (children, the poor, the disabled, the elderly, etc…) We must constantly watch and modify these programs, however, not only to ensure their costs are controlled but also to ensure they are accomplishing their goal – better health for these groups of people. More funding does not always mean better outcomes, so strict oversight is needed.

I agree with you that socialized medicine is not the best answer, nor is it a magical solution to our declining position in the global economy. Importantly, I also believe that private insurance coverage for more and more healthcare goods and services is not the answer. As I have mentioned before, until we begin to limit the number of parties intervening (and either extracting profit from or adding costs to the process) in the doctor-patient relationship, costs will continue to rise and patients will continue to relinquish control over their own care. We need to move toward empowering patients and physicians, not toward having healthcare decisions mandated by any other entities (private or public). Thank you for the thoughtful contribution here.

querywoman

Dr. Collar started out by alluding to a health care as a, “right.” This refers to the American constitutional and other legal systems.
American health insurance companies violate common laws at every turn. They mislead doctors and patients at every turn. They twist advertising. Burying an exception on page 63 in one small paragraph can be construed as false advertising.
They repeatedly delay payments to doctors, and let their money sit in banks and draw interest.
They change prices at whim without adequate notice, like my Victoza.
Nobody every legally stuck them in charge of health care, but the government has let them be. If you go to a government hospital, they want to know if you have private insurance and are happy to bill the insurer.
If the health insurance companies were forced to comply with American laws, we’d all be better off.

Luis Collar, M.D.

I was alluding, first and foremost, to consistency. Specifically, if as a society we decide health care is a right, we would need to develop policy that is consistent with that value and then ensure that all entities operating in that system are treated similarly with regard to profit, regulatory oversight, etc… Likewise, if we decide that it is a “business,” then all parties in the industry should be treated equally. Currently, there are huge disparities in how different entities operating in the same industry, or equally critical industries, are treated.

I do agree that we need to take a very close look at the role insurance companies play in driving costs, infringing on patients’ autonomy and physician therapeutic independence, and, too often, manipulating physician reimbursement in ways that are of no benefit to patients, physicians, or our society at large. We also need to look at ways to limit the role the insurance industry plays in health care, not continue to increase it. They exert disproportionate influence the doctor-patient relationship that is not in patients’ best interests.

querywoman

Thank you for explaining more. I agree that the inconsistency is wrong.
My gripe with SilverScript is about inconsistent Victoza pricing.
Last night I changed to an AARP Medicare D Plan.
I will be filing formal state and federal complaints against SilverScript.

Judgeforyourself37

I was saddened but not surprised by some of the posts. Yes, in my opinion as a retired RN, health care is a basic right. It is in other nations, but not here. Why? From what I read the reason is the greed that is so rampant in this nation. Greed, and by that I mean corporate and individual greed.

querywoman

And other countries still get doctors, who are paid mostly well, except in Cuba. And many foreign doctors complain that they would make more in the US.

Luis Collar, M.D.

Though greed is certainly a part of the problem (as it is in virtually any other industry), one cannot attribute all of the problems with healthcare solely to greed by “all” of the parties involved. The problems are a bit more complex than that, with the motivation / systemic treatment of different parties within the system being, in many cases, vastly disparate.

hawkeyemd1

Greed is everywhere, but there’s a big difference between greed and feeling that more and more things are entitlements. Corporate greed is one thing that definitely needs to be addressed in healthcare, but if everything is a right or an entitlement, what happens when the government runs out of money. Oh, wait…it already did. National debt gone wild.

Luis Collar, M.D.

And making something a right or entitlement never assures that what you are protecting is of any particular quality. Freedom of speech allows us to express ourselves openly and freely, but it doesn’t guarantee that the thoughts expressed are intelligent. Moreover, if we had approached freedom of speech the way we are approaching healthcare, we would have mandated that all individuals must pay the publishing / media industry a “fee” to secure the right to read and write freely and be heard (after all they are the gatekeepers of TV, the internet, books, etc..much like we have made insurance the “gatekeeper” to healthcare). But would that help citizens exercise their freedom of speech or even improve literacy? Would that industry profit disproportionately despite only being a gatekeeper that doesn’t actually create the books and movies it profits from or teach people to read and express themselves? Sounds far-fetched and silly, but it really isn’t any different than mandating insurance and assuming health will be improved and costs will be controlled. The key to improving access and outcomes is to gradually remove insurance from the equation, not increase its role in the process.

PoliticallyIncorrectMD

What are you smoking?! In the US top 10% of earners pay 70% of taxes. You call this regressive?

querywoman

FatherHash said my lament over upped Victoza prices, “may be selfishly skewed.”
His dissing of me seemed to be very popular.
But when I pop back and question lavish physician lifestyles, I get dissed.
To Those of you doctors who diss a patient for complaining about insurance policies while griping freely about how insurance companies mess you over: do you show this attitude in public?
Go ahead and do it! You are not doing your profession any favors!

querywoman

I disagree that, “The Affordable Care Act just perpetuates the problem.”
It’s destroying the current system, not providing adequate replacement, and bring a decade of confusion.

querywoman

For me, a civil right is adequate public transportation. Cars are a socially new thing.
I want the right to hop a city bus in any town, which is not possible throughout much of Texas/

Luis Collar, M.D.

Thank you for all your thoughtful comments. This may be unrelated, but two of the public hospitals I’ve worked at provided tickets for public transportation to and from the hospital and to and from office / clinic visits for certain patients. I’m not really sure what criteria was used to determine who got them, though. And this was a local program here, so I’m not sure if TX has anything similar in place. I know it wouldn’t solve all transportation issues for you, but it might be worth looking into at some of the places where you receive care.

querywoman

Thanks, but that’s not my issue. I’m not that poor. I ride the bus cheap, walk, and can buy an occasional cab.

My own city has public bus service and rail, but not some of the surrounding ‘burbs.
I’m not missing much by staying out of those ‘burbs.
I could walk about a mile into one, the one my family moved into when I was 17, but not much I care to do there that I can’t do in the big city.
However, I was recently on the phone with a guy who has a neurological problem, can’t walk more than a block, and has trouble walking on and off a bus.
He really needs the local public handicapped bus system, which I told him he needed.
His Soc Sec is about 20% higher than mine, but he can’t afford a cab since he spends it all on cigs and beer.

Luis Collar, M.D.

Thanks for your comments. I would only add that, even in countries where healthcare is nationalized, there are often huge geographic differences in quality of care and patient experience (not unlike the geographic differences often found in this country). So, while your acquaintances’ accounts are undoubtedly accurate depictions of their own experience, they are not necessarily indicative of the collective experience of the entire nation. Even though the policies are national, the bureaucracies and individuals actually administering the programs locally can differ greatly with regard to budget, staffing, and training, not to mention the nuances and complexities involved in serving distinct patient populations with overly centralized control / guidelines / protocols, etc… So patient experience within the system can vary widely from province to province (again, not unlike it often does in this country from state to state).

querywoman

If anyone cares to read this, it might help you to help your own patients.
Victoza is a Tier 2 Drug. I could request an exception, with a doctor’s note, that it be lowered to Tier 1. Then I could get it cheaper, free, all year, no copay, on my current plan.
But I’m willing to pay $34 all year.
I will probably change my plan.

Because I get state assistance with Medicare D, I cannot get it free from the manufacturer after I hit the donut hole. Your patients, I think under 200% of the Federal Poverty Level or maybe even more, could also get their expensive drugs free after hitting the donut hole.
An exception needs a letter from a doctor. I’m a professional bureaucrat, so I’d probably word it for my doctor and let him do it professionally, emphasizing how much my insulin costs if I don’t use.
The paperwork for this stuff is a real pain for most doctors, though!

Now, if SilverScript were to waive my $34 to $75 copay, I bet they would get a “kickback” from the drug company for the premium, which surely beats giving me a $500 drug totally free every month.

querywoman

One dislike already as I explain how I can get a medicine that provides much better disease control!
I don’t even take the highest dose. I shoot 12 units instead of 18 units. I use an insulin syringe to draw the last tad out.
Sometimes I go to sleep without taking it. I can handle that an occasional night, but not two nights, as I have done. I recently wasn’t drawing up my full 12 ml, trying to make it last a little longer.
Then I started binging some and my sugar began climbing some. Going up to the full 12ml fixed that.
I told my doctor.
I have been taking the full 12 ml consistently for about 3 weeks. My sugars were running 130 to 150 in the morning.
I woke up with a 92 fasting sugar today.
I knew I was getting better.
I recently told the doc I was thinking of going up to full 18ml. He told me to half the glimepiride if I did that, and eventually I may not need it at all.
Wisely, I waited to see if I would stabilize from getting the full 12ml regularly.

ivyleagueteapartier

Health care is a business. Nobody has a right to expect other people to work to pay for their health care, which is ultimately what that boils down to. If you believe that people should have care that they don’t pay for themselves, there are plenty of charities that you can donate to in order to make that happen. Spending you own money charitably arguably makes you a better person. Spending other people’s money charitably makes you a Marxist.

querywoman

The current health care financing systems in the US have caused unequal access and wildly different prices.
The best way to get fair consistent, health care pricing is to drop all third party payment systems.

Luis Collar, M.D.

I agree with you… The issue isn’t that physicians are evil or that patients don’t want to pay… In my opinion, one of the biggest problems we have is that third party payment really doesn’t benefit patients or physicians… Once again, thanks for you comments. I’m currently writing about this very topic, so I trust we shall be discussing this again soon. 🙂

querywoman

This topic getting really bursty. I’ll make a few more comments. I often reference a time in the 1980s when insurance was $200 deductible, and 80% reimbursement after that.
My doctors wanted cash pay and would not accept insurance assignment. Some wanted more than reasonable and customary charges.
After the small copayment system came into being under managed care, payment was not a problem for me.
If you have always practiced with the small copayment system under managed care, then the older way is unknown to you.
You tried to “help” me in the way you know how, assuming I might need help with medical transportation. I don’t. I ride the bus all day for $2.50 in a large geographic area.
That’s just it. The world does not revolve around medical care and medical-related needs. Other social and cultural issues are equally important.

Luis Collar, M.D.

Thanks for your comments. I do believe society has a vested interest in ensuring its most vulnerable citizens have access to care (e.g. children, the elderly, the disabled, etc…) For the vast majority of the population, however, I agree with your conclusions. As a matter of policy, empowering individuals to spend their own health care dollars is much more effective (e.g. properly allocating resources, controlling costs, alleviating costly administrative burden at the point of care, improving outcomes, etc..) than allowing any third parties (government, the insurance industry, etc…) to direct those investments.

hawkeyemd1

Indeed.

querywoman

I finally made contact with SilverScript rep after complaining to Medicare. She has already sent a request to lower the tier copayment on the Victoza to my doctor.
I just faxed him some stuff also.
She said it was hard for her to figure out too.
All you naysayers, thumbing me down! I’m flexible. Insurance companies aren’t that bad, if you know how to deal with bureaucracies and get through the stuff.
Nevertheless, most of you doctors are not very good bureaucrats or paper pushers and the current system has forced you into it!

agent50

Mandy M.—“rights we were born with”—-So why then aren’t the citizens of communist countries “born with” those rights?—could it be that the state took those rights away somehow?

Luis Collar, M.D.

I agree that the ACA is not doing enough to bring consistency (one way or the other) to the increasingly “hybrid” system we find ourselves with. Unfortunately, this problem has been around for decades now. It did not begin with the ACA and involves many other players, most notably, the insurance industry. We need to decide what our values are and then develop policy that consistently applies those values across healthcare and other industries of equal importance to the human condition. Thanks for the comments.

Luis Collar, M.D.

Thanks for sharing your thoughts. While we must consistently look to other countries to see what is working well internationally, as a matter of policy, I would be cautious in assuming what works in other places will work here. Our nation has a unique history (politically, culturally, economically, etc…), and so importing policy, so to speak, from other countries will not always yield similar, or even the intended, results. A better approach is to look internationally for lessons learned and use the information to develop our own policy, policy that recognizes our tradition of individual liberty and free market solutions. Health care policy cannot exist in a vacuum; it must always be consistent with the unique political, social, and economic context of a given country.

querywoman

Martin White, I was a public welfare worker over 9 years, working one on one, at a salary making much less than a medical doctor.
I knew I made my living off human misery.
From what I see, many doctors do not appreciate that their patients are sick people who have no choice but to use their services.
This is a simple fact in a capitalistic societies! Appreciate your customers!

querywoman

I have just been discussing on the phone with another person how student loans can be deferred or put in forbearance.
And how I do not feel sorry for people who got a bachelor’s degree at public expense but do not know how to contact their student loan financiers and work out agreements.
I am not the only one who has called it, “indentured servitude.”
It differs from indentured servitude in that there are options to get out of payment. Your wages can be garnished if you don’t cooperate. Or you can constantly switch jobs. Or you can collect cans, live on the streets, and grub for a living.
Adolph Hitler was a street bum before he came into power. Probably did lots of scheming, thinking, and planning.

querywoman

Martin White, whomever you are, I feel your personal resentment.
Would I have made such a comment if I had not seen SOME doctors who don’t appreciate their patients?
Let’s see, my SS is a little more than $15,000 a year. I live okay. What do file on your income tax per year? It’s none of my business. I currently have a student loan, and it is Income Based Repayment. My current payment is ZERO! I could take a disability forgiveness, but in a few years Ill get a state pension as well.
I no longer shop at Walmart or Tom Thumb because they don’t appreciate me.
It is a fact that doctors make money on people who are sick and unfortunate enough to need them, just like my electrician father made money off the companies who needed his own services! My deceased electrician brother spent years working in a hospital. His electronic ghost is still flowing through the currents of that hospital.
Do you know what it’s like to spend all your money on doctors, still be sick from what they wanted to do while neglecting me, and have to save up more money to see another doc and try again?
Do you know what it’s like to drive sick in the Texas heat to a doctor’s office in an un-airconditioned car? I realized I was wasting my money on him.
I have had doctors in my social/church circle. Some I thought of us friends.
I brought up the issue here of physician lifestyles after I got
kneejerked that I was “entitled” for wanting my Victoza costs to be
stable all year.
The kneejerk reactions I received here are probably related to years of doctors not having to face criticism. Those times are coming to an end.
But it was okay to blast me as a lazy entitled patient. When I get my medicine consistently, I get better control. Sometimes the expense makes it hard for me.
I went to my doctor a few weeks ago and my sugars were climbing a little but I told him how I self-adjusted my glimepiride pills to half, none, half, and then back up to full as needed. And that was fine again. I think I may have forgotten to use it one night since I saw him. I am halving my glimepiride again.
If you read every single one of most posts, click on querywoman, you would find that I used to attend a large urban church with doctors, lawyers, programmers, CIA spies, urban planners, and other well-paid professionals along with a few homeless.
I taught the children of the upper middle class in Sunday School for years while working in public welfare. My upper middle class children had a very big problem: their parents usually worked 80 hours a week.
In my Sunday School classes, I had a few children whose doctor parents had been practicing a while, made some money, and spent quality time with them.
I had one child who deeply resented the fact that his father was a “resident.”

querywoman

Tam, it’s almost a pity that you have quieted down. America is technically a republic, not a democracy.
Medical doctors are only a small percentage of the voting public!
Wake up and smell the hot chocolate!

querywoman

Thanks to the couple of doctors here who appreciate me and commended me for my better disease control here.
Because I do not work, I will share my bounty as I am able. I do taxes for friends, who usually simply buy me a meal.
Sometimes I help people with Social Security and food stamp matters, but that can be a real pain due to their personal irresponsibility.

querywoman

In your case, how would you deal with sleep deprivation in medical school? Since you call yourself, “PreMed,” you must not be there yet.
I hope you make it through, but if you don’t, you tried.
We really don’t know, PreMedGirl, how many practicing doctors actually seem to hate and resent their patients and the money spent on them.
Do some doctors see their customers as billing units for insurance companies instead of patients?
Good luck, dear heart!

Luis Collar, M.D.

Thank you for the thoughtful comments. I do believe we must have a strong safety net for those that are vulnerable in our society (e.g. children, the poor, the elderly, the disabled, etc…). This is why I believe programs such as Medicaid and others that protect these groups need to consistently be scrutinized to ensure they are effectively and efficiently accomplishing their goal — improving health (more money doesn’t always achieve this goal, so they need to be properly managed). The goal of the article was to pose the question for the system at large precisely because our current policy is not consistent. Many players in the current system (pharma, insurance, large health systems, etc…) are, in fact, treated, from a policy perspective, more as businesses. Individual physicians are often asked to disproportionately bear the responsibility for cost reduction despite not representing the most significant profit center or even being the largest drivers of cost within the system. The point was simply the need for greater consistency within the system and across other industries that provide similarly critical goods and services, no matter what direction we choose.

querywoman

Dr. Collar, I have a BA in English and history. History tends to repeat itself, except in one way that it changes.
Frauds come and go.
In the 1920s it was Teapot Done, about oil leases. My father said, when he was young, like in his twenties, liquor was the big racket.
Insurance and probably some major players, like hospitals, are surely involved in all kinds of racketeering and colluding. Sadly, the contemporary scandal revolves around sick people.

I am interested that many of the respondees would rather bash me here than answer whether or not they have ever bargained with an insurance company.
Have you ever bargained with an insurance company? I forgot what your specialty is…are you even in a private practice?.
My understanding is that for most doctors the insurance companies are just take it or leave it at this price.
I worked for the IRS briefly. One of my trainers says there is a whole segment of insurance law that, though it remains name concealed, applies only to Blue Cross Blue Shield. He wouldn’t tell use where it is, said we’d have to research it ourselves.

Luis Collar, M.D.

I have “negotiated” with insurance companies, both as a physician and on behalf of friends / family members who have asked me to do so. Generally, as in any negotiation, it is difficult when not in a position of power (e.g. large health systems, big pharma, etc… all have greater leverage than individual patients or physicians).

querywoman

Thank you for trying to answer. Are you “negotiating” to get a service covered?

What I am referring to is a flat fee for something like a family doctor routine visit.
I have always assumed there is collusion on fees between really big medical entities and hospitals.
The practice of charging disparate groups different rates would be illegal in any other industry!
Teapot Dome was complex, but I think it was about price fixing. The current health environment is much more complex. Many more layers and many more players!
I say the little person in the field, the doctor, is in a take it or leave it position.I just googled: “health insurance hospitals government racketeering.”
I would really like to delve more deeper. Just look at the alleged IRS section written to benefit Blue Cross Blue Shield and only them!
Fascinating. Must do some household chores now.

Luis Collar, M.D.

I agree incentive is key in any effective, efficient system Additionally, the current third party financing in health care, almost exclusively dependent on the insurance industry, does not always effectively align patient / physician / systemic / societal interests with each other and bring the right incentives to bear.

querywoman

The US Constitution is an incredibly flexible document that’s stood the test of time. We no longer have slavery.
The current medical system did not exist at the time of American Independence (reworded, at the time of successfully stealing a chunk of the East Coast from the Native Americans.)
In reality, we have an unequal health care system with unequal access. That violates the rights of all people, not just men, to have life, liberty, and the pursuit of happiness.

hawkeyemd1

But so many things contribute to our ability to “have life, liberty, and the pursuit of happiness.” How do we decide which ones should be rights paid for by citizens and administered by the Federal government?

querywoman

Dr. Collar states his initial post was about inconsistency.

The federal government is not the only player in the medical field. State and local governments pay plenty for health care, as do employers and the little people, “employed policy holders.”
Health care is a favorite love-to-hate cause, and there any many abuses in the current system.
In effect, health care is already a civil right for the truly poor, but not for the rest of us.

I maintain that the current system is unequal and full of abuse. Insurance companies break all kinds of law. The bizarre practice of charging different classes of people different prices for the same service would be illegal in any other business.
I have been giving documents indicating that a hospital and a pharmacy, Walmart, were paid a certain amount for a service when they actually received less. There’s a word for this: fraud. Since the info is now transmitted electronically everywhere, it’s wire fraud..
I don’t have the answer, any more than anyone else.

hawkeyemd1

I don’t think anyone’s got all the answers. Feels like too many people have their hands in this, though, making it more complicated than it should be.

querywoman

Hawkeyemd1, one thing I can promise you is that the insurance companies are engaged in massive racketeering and collusion, “fraud,” in the management of sick people.
If we enforced our laws, we could redistribute the money.
If you check in a government hospital, they ask if you have private insurance and will be happy to bill your private insurance.
I fail to see why the issue of coverage for the poor keeps popping up on these boards. Most of the poor already get free care, at government expense.

hawkeyemd1

I agree on the insurance company corruption, but how, then, is having the government pad insurance industry pockets by mandating more coverage any better? I see your point and not being difficult here, but I wasn’t just talking about the poor… Just doesn’t seem to make sense to force insurance AND government into it if both are susceptible to corruption, waste… That’s what I mean by increasingly forcing more hands into this.

querywoman

Hawakeyemd1, we don’t even know what the ACA is yet. If you have read me before, I worked for my state in welfare and have also worked for the IRS.
What’s coming with the ACA is sheer and total chaos, which I predict will take ten years to level out.
When I research ACA for my friends, one of whom is a millionaire AND a lawyer and more lower income friends, it’s weird. The lawyer can afford a $500 month premium.
But I see that many of the middle middle class are actually exempt from the ACA because the premium is more than 10% of their modified annual gross income.
So how does the ACA affect anything at all?
The uninsured upper middle class, like commissioned salespeople, who have no insurance right now, will have access to and can probably afford ACA plans.

Luis Collar, M.D.

Outstanding point. Thanks.

Luis Collar, M.D.

This is a key concept. If healthcare is a right, the next question needs to be what constitutes healthcare? Treatment for serious illness? Catastrophic injury? Preventive care? If the idea is that preventive care saves costs in the long term, then what about food? The data regarding healthy eating is even more compelling than preventive medical care with regard to its ability to help control long term healthcare costs (diabetes, heart disease, etc.). And yet we don’t have “coverage” to make healthy foods more affordable, nor do we mandate, federally, what foods to eat or how much grocery stores and restaurants can charge for food. (Food stamps are in no way equivalent to the current national push for increased coverage). We try to accomplish healthy eating in different ways. Diet, exercise, education level, household income, employment status, meaningful relationships, limiting environmental exposures, quality housing, prevention of violence, etc… all contribute to improved health and decreased healthcare costs. Most of these have a greater impact on health and long term costs than an isolated colonoscopy screening or PSA level. Why set those aside as worthy of government subsidy / mandate, and not exert the same influence in other areas that are even more critical to improved health and lower costs. We need to educate and empower patients to determine the best ways to spend their own money and lead healthier lives, not further increase the role that the insurance industry plays in medicine and continue to increase the distance between physicians and patients. More coverage won’t control costs or improve health. Genetics, socioeconomic realities and individual choices determine health and costs. Focusing on insurance and not the others, and then treating physicians differently than insurance, biopharma, pharm benefit managers, etc…, is inconsistent and ineffective.

hawkeyemd1

Agreed. Not everything we want or even need is automatically a right others must pay for.

hawkeyemd1

We are not “most” nations. We used to lead in many areas, and we need to continue to lead. The US needs to find ways to be a leader, not just copy what other countries do because it is more acceptable or feels more pc.

Luis Collar, M.D.

And we need to do things that make sense given our particular form of government, our history, our culture, how we value our freedom etc… Good policy is like good medical care in that both need to take into account more than just the isolated problem at hand. Political and socioeconomic context are critical, so what works best in another country is not necessarily best here (the two “organisms” are similar but, in some ways, unique).

hawkeyemd1

I agree we need more compassion for the ill. But who decides what care should be given and at what cost? Should some receive more and others less? Who gets what? Those are real decisions that have to be made when the government doesn’t have unlimited money. Sure, can keep running deficits, but if the spending finally catches up with us, there will be less care not more.

hawkeyemd1

Couldn’t agree more. Food, education, shelter, technology, and so many other things help us compete…All are important, so how do we decide which should be rights, which should be provided by the government…? The government can and should facilitate some things and help set a direction, but it can’t pay for everything that people want or everything that we need to be competitive. Individual citizens and the free market can and should do much of that.

Luis Collar, M.D.

Again, great point. hawkeyemd1.

hawkeyemd1

Agreed. I think the point of all this is that people don’t realize taxes (federal / state budgets) aren’t unlimited, even if they tax citizens at 100%. We can’t make everything a right and then just hope the money turns up.

hawkeyemd1

They key is balance, I think. We have to have compassion, but there have to be boundaries. If we only rely on public funds, we’re doing ourselves a disservice…that money isn’t unlimited and if we bankrupt these programs or the country, then what happens to the “rights” we all wanted?

Luis Collar, M.D.

Thanks for the comments. We need to make sure the most vulnerable in our society are cared for compassionately, but we also need to be sure we are consistent in our approach to policy.

Luis Collar, M.D.

Again, I don’t disagree that government should play a role. The question is specifically what role they should play And health insurance is not a silver bullet. Disease (and the costs associated with it) is complex. There are other ways for the government to lead that don’t involve increasing the role of the insurance industry by mandate. And, most importantly, federal policy needs to be consistent across all aspects of life that influence health and healthcare costs. Artificially picking and choosing some and not others is not only ineffective but also leads to the creation of profit “winners” and “losers” within healthcare that is wasteful and contributes nothing to the health of the nation.

Luis Collar, M.D.

And not in a “political” sense but specifically from a medical perspective… Individual responsibility and policies that educate and empower the individual will be the most effective at improving health and controlling costs. No insurance policy will prevent individuals from making poor health choices in a free society. Only an individual, in consultation with physicians when needed, can make the right choices. All other parties are extraneous and generally a waste of resources.

Luis Collar, M.D.

Thanks for contributing. It is also true, however, that part of the reason it is “too expensive” is our increased reliance on insurance in healthcare to begin with. Policy shouldn’t be developed without first having a clear understanding of the philosophical imperative that will drive it. If you just throw a plan together that lacks a consistent philosophy at its core, it leads to waste and the unequal treatment of different entities operating in the same space, with some profiting disproportionately despite not adding anything of value to the process.

Shane Irving

I think there may be a third path to consider if we look at this a little differently. If we put aside the argument of Business vs. a Right and look at this purely financially.

Right now Healthcare in the US is consuming around 18% of our GDP. Why? Because of inefficiencies, bureaucracies, for profit pressures and the list goes on and on..

Why is it that other industrialized countries can provide better care for their total populations for between 8-10% of GDP (and some less than that)?

Yes, many of them may consider it a “Right” and have higher taxes, but still this centralized core approach works and how much better off would the US be if 8-10% of GDP went back into the economy?

Maybe it should be Business vs. Right vs. Smart?

Luis Collar, M.D.

Really interesting to see how many of our problems are not new and have been dealt with throughout our history. I tried to find the article, but only got some ebay listings to order the old reader’s digest magazine. If the entire article online anywhere? Either way, thanks for bringing it to our attention.